REPUBLIC OF THE PHILIPPINES )

MABALACAT, PAMPANGA ) S.S.

AFFIDAVIT OF LOSS

I, ROSEMARIE C. LAXAMANA, of legal age, married, Filipino and with residence and postal
address at 1654 T. Alonso St., Claro M. Recto, Angeles City after having been duly sworn to in
accordance with law do hereby depose and state:

1. That I am a bona fide voter in which I was issued a Voter’s Identification Card by COMELEC;

2. That I usually keep said Voter’s Identification Card inside my lady’s wallet;

3. That on May 20, 2011 at about 9:15 a.m., I boarded a bus going to Manila bringing with me my
lady’s wallet which I placed inside my shoulder bag;

4. That when I was about to alight the bus, I noticed that my bag was slightly opened which prompted
me to look for my wallet;

5. That upon opening said bag, I discovered that my wallet was missing along with the Voter’s ID Card
kept inside it;

6. That I have exerted earnest effort to locate the same but in vain most probably have been snatched
from my bag;

7. That as of this date, said Voter’s ID Card kept inside my wallet which was snatched from my bag is
still missing and can no longer be located;

8. That I am executing this Affidavit of Loss to attest to the truth of the foregoing facts and
circumstances.

IN WITNESS WHEREOF, I hereby affixed my signature this 8th day of August 2011 at Mabalacat,
Pampanga.

ROSEMARIE C. LAXAMANA
Affiant

SUBSCRIBED AND SWORN to before me this 8th day of August 2011 at Mabalacat,
Pampanga, affiant is personally known to the undersigned but exhibited to me his/her ID No.
___________________, personally known to me to be the same person who personally
signed before me the foregoing and acknowledged that he/she executed the same.

Doc. No. _______;

Page No.________;
Book No.________;
Series of 2011.